Why Jewish Medical Ethics

An introduction to the system of Jewish Law.

In many ways, the Jewish approach to medicine is the opposite of the
secular approach. As I described in my in my previous article, many ethical lapses over the past century have been the
result of placing the good of society before the good of the individual.
In Jewish theology, the individual is of paramount importance. This is
aptly stated by Rabbi Jonathan Sacks, current Chief Rabbi of the British
Commonwealth, in his book, A Letter in The Scroll, regarding the
contribution of the Jews to the world's concept of morality. He writes:
"In eras that worshiped the collective- the nation, the state, the empire-
they (the Jews) spoke about the dignity of the individual." In another
section, Rabbi Sacks crystallizes the crux of the Jewish contribution to
civilization:

"In terms of ethics, Judaism was the first religion to insist upon the
dignity of the person and the sanctity of human life. For the first time,
the individual could no longer be sacrificed for the group. Murder became
not just a crime against man but a sin against God."1

This lesson is apparent from the first chapters of the Torah where we
learn about the circumstances of man's creation. The Torah2 tells us
that "God created man in His own image" to teach us that every individual
person is Godly. If every person has the spark of God within him, how
could we ever contemplate treating any individual with anything less than
the utmost respect and dignity?

The Talmud teaches that the Almighty first created mankind as a single
individual, rather than a group of people, to teach us that one who saves
a single life saves a world, and one who destroys a single life, destroys
an entire world.3 According to the Jewish view, the individual is a
microcosm of the entire world.

Practical Ramifications

We see that the individual is of intrinsic importance manifested in Jewish law in a multitude of areas. For example, an innocent person's life may never be sacrificed to save someone else or even a group of people. Nevertheless, although we recognize the validity and necessity for triage and rationing in some situations, we do not sacrifice one person's life to save someone else's life.
If two people are drowning and we can only save one, or if several people need a medicine and we only have enough for one, what do we do? Mainstream Jewish law would have us save one even if others will die. Although we choose to save a particular individual and others may die, we have not directly caused their deaths. However, we could not kill one person in order to save another, unless the party we are killing is a rodef, someone pursuing another to kill them (see: Abortion in Jewish Law).

Regardless of how sick an individual may be, we may never harm him to save someone else. While the secular word entertains the idea of removing organs from very ill patients by obtaining consent to withdraw life-support, halacha unequivocally rejects the idea of sacrificing the life of even the sickest patient to save the life of another. This does not imply that halacha bars cadaveric or live organ donations, only that one may not kill one person to save another.

A General Approach

1. Good ethics start with good facts. 2. There is no distinction between Jewish law and ethics.

The Jewish approach to any ethical question relies on two important concepts: that good ethics start with good facts and that in Judaism, there is no distinction between Jewish law and ethics.
Judaism does not deal with armchair philosophy; it deals with real, practical cases. I learned the first rule after speaking at the International Conference on Jewish Medical Ethics in San Francisco several years ago. At that time a major scandal had just come to light in Israel. It was revealed that the Magen David Edom, the Israeli version of the Red Cross, was throwing away the blood of Ethiopian blood donors without informing them, for fear that the blood was tainted with HIV. There were angry accusations of racism.
Dr. Avraham Steinberg, a pediatric neurologist at Shaarei Tzeddek hospital in Jerusalem and prolific author on Jewish medical ethics, was asked whether it was ethical to secretly discard the Ethiopians' blood. He replied: "Good ethics start with good facts." He explained his analysis of the situation in a most ingenious way. If the HIV rate in the Ethiopian population is not significantly higher than the general population, then discarding the blood is immoral. But if the HIV rate in the Ethiopian population is significantly higher than the general population, then other factors come into play. It must be understood that testing donated blood was expensive and there was a window of time between HIV infection and conversion to a positive HIV test. If the yield of clean blood after expensive testing for HIV is so low that it is not economically viable to test, and the risk of HIV tainted blood entering the blood supply is high enough, then secretly discarding the blood is not only prudent from a medical and economic point of view, but shows respect for the Ethiopians by not publicly labeling them as diseased.

If one questions the wisdom of such an approach, one need only look to the American Red Cross. After a potential donor is finished donating his or her pint of blood, the donor chooses a bar code that indicates whether their blood should be used or should be discarded. Why should such a system be necessary? Why would someone donate blood and then ask to have it discarded? Because the drive to avoid embarrassment could force a person to donate due to peer pressure even if they know that their blood is, or could be, tainted. So the Red Cross offers a tactful, confidential way out that prevents embarrassment to the donor.

What is ethical is not always obvious. The question of whether an action is ethical can only be made with respect to the exact facts and merits of each specific case.

The second rule, that there is no distinction between Jewish law and ethics, is more straightforward. From a traditional Jewish approach, Jewish Law, halacha, defines ethics. Halacha is the code of conduct by which the traditional Jew leads his or her life. Extra-halachic ethics is somewhat of a non-sequitor. We apply Jewish law to each case and the answers that we reach should represent an ethical paradigm. For this reason, Jewish medical ethics is merely the application of Jewish law to medicine, just as kashrut is the application of Jewish law to food, or Jewish tort law is the application of Jewish law to monetary damages.

How are medical ethics questions approached?

Every day, new medical and technological breakthroughs occur, widening the panorama of therapeutic options. While the march of technology continually improves our health, it creates new scenarios and novel questions. How does the Torah approach what sometimes appear to be unprecedented situations?

Regardless of how unique as situation may appear, the approach of the halachic system remains unchanged.

Regardless of how unique as situation may appear, the approach of the halachic system remains unchanged. As the book of Ecclesiastes states: "There is nothing new under the sun." 4 Infertility treatments (including IVF and surrogacy), artificial prolongation of life, abortion, rationing, self-endangerment, and a myriad of other contemporary ethical issues have been dealt with in Jewish law for millennia. The challenge is to appropriately recognize the salient issues in order to properly apply Jewish law.

The Jewish legal system

When one approaches a rabbi with an ethical question, whether in medicine or any other facet of life, how does the rabbi determine the appropriate answer? While the secular approach of a hospital ethics committee relies heavily upon personal feelings and experiences, the Jewish approach relies upon an evaluation of pertinent information from a rich heritage of over 3000 years of Jewish existence.

To understand how any specific question of medical ethics is answered, one must understand the Jewish legal system. The methodology for investigating any halachic or ethical dilemma is similar. The posek, or rabbi who has been extensively trained in Jewish law, gathers technical and situational information about the case at hand. He then surveys Jewish legal sources from the Bible to the 20th century, identifying precedents from previous cases that might be applicable to the current case. He then carefully traces the relevant issues through the Torah, Mishna, Talmud, Rishonim (early Talmudic commentaries), and Achronim (later Talmudic commentaries), using prior halachic literature to guide the application of Jewish law to modern problems. After tracing the path of Jewish law from the Torah to modern responsic literature, he renders an opinion.

Structure of the halachic system

The structure of Jewish law is in many ways analogous to that of Western legal systems. While the analogy is somewhat simplistic, it is instructive to give a sense of how the halachic process is organized.

Just as the written basis of the United States legal system is the constitution, the Torah5 is the basis of the halachic system. The Torah is a written Divine document that God presented to the Jewish people on Mount Sinai and which contains all of the mitzvos and other important concepts of Judaism.

American law rests on a long tradition of common law extending back many centuries to Great Britain and even to ancient Rome. This component of the secular legal tradition is much larger and more far-reaching, but is equally authoritative and comprises the basis for much of the case law generated by the courts. Similarly, the Mishnah, 6 Talmud7 and other components of the Oral Law are much more extensive than the written Torah and equally authoritative. The Oral Law is the corpus of Jewish law that traces back to the revelation at Mount Sinai and which includes later rabbinical legal decisions, which flesh out and explain the Torah. The Oral Law deals with the day-to-day practical aspects of Jewish life.

Like any Western legal system, our laws are compiled into statute books. Just as there are tomes of federal and state laws, we have compilations of Jewish law dating back over 800 years. The earliest extensive organized compilation of Jewish law was performed by Moses Maimonides, a great rabbi and physician of the 12th century. His Yad Ha'chazaka, also known as the Mishneh Torah, 8 covers all areas of Jewish law and remains one of the most authoritative legal guides in Judaism. The next great statute book, the Arbah Turim, was written by Rabbi Yaakov ben Asher9 in the early 14th century. Probably the most famous compilation of Jewish law is the Shulchan Aruch (Code of Jewish Law), written by the Sefardi posek Rabbi Yosef Karo who lived in Safed, Israel, with glosses by the Polish Ashenazi posek Rabbi Moshe Isserles. 10 This seminal work was completed in the late 16th century, and while hundreds of subsequent commentaries have been written, it remains the preeminent guide to Jewish law.

Where do we find the final decision?

Probably the most useful halachic literature for evaluating medical ethics issues from a Jewish perspective are the many thousands of responsa written over the last thousand years that deal with every conceivable aspect of life. This is akin to the corpus of Western case law dating back many centuries that has formed the precedents for modern court cases.

While many great rabbis dealt with a broad range of issues, some were considered to be particularly expert in the area of medical ethics. 11 In America, Rabbi Moshe Feinstein (1895-1986), author of the multivolume Igros Moshe, was widely accepted as the preeminent posek in all areas, but particularly in the area of medical ethics. His decisions span all areas of medical ethics. In Israel, Rabbi Shlomo Zalman Aurbach (1910-1995), author of Minchas Shlomo, was accepted by many as the greatest authority in these areas. Of course there are many other great rabbis who deal with medical ethics. Among the greatest living experts are probably Rabbi Yosef Shalom Eliashiv, author of Kovetz Tshuvos, and Rabbi Eliezer Yehuda Waldenberg, author of the 20 volume (so far) Tzitz Eliezer.

Conclusion

Judaism has very rich tradition of medical ethics. Questions that the rest of the world finds novel have been dealt with in a variety of ways in halachic literature for hundreds, if not thousands of years. We have a comprehensive system that has been field-tested for reliability and which does not bend to the transient whims of society or the changing winds of fashion. Without a gold standard for comparison such as the Torah, situational ethics can become a very slippery slope. Murder becomes "mercy killing," destruction of fetal life becomes a "personal choice," and the basic rules of human dignity upon which society should be grounded erode beneath our feet. With our extensive, proven track record of morality that stems from a Divine source and that stresses the nobility of all human beings, we are highly qualified candidates to enter the societal debate over public policy issues involving medical issues.

1 Sacks, Rabbi Jonathan, A Letter in the Scroll, p. 75

2 Genesis 1:27

3 Sanhedrin 4:5

4 Ecclesiastes 1:9

5 The Torah was presented to the Jewish people in 1313 BCE

6 The Mishnah was compiled by Rabbi Yehuda HaNasi in approximately
190 CE.

7 The Babylonian Talmud was compiled by Rav Ashi and Ravina.in
approximately 500 CE. The Jerusalem Talmud was compiled by Rabbi
Yochanon in approximately 350 CE. Exacts dates vary.

8 The Mishneh Torah was written around 1180 CE. Maimonides lived
from 1135 to 1204 CE.

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About the Author

Dr. Daniel Eisenberg is with the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine. He has taught a Jewish medical ethics class for the past 15 years. Dr. Eisenberg writes extensively on topics of Judaism and medicine and lectures internationally on topics in Jewish medical ethics to groups of all backgrounds. Obtain more information on scheduling a lecture or learning more about Jewish medical ethics by visiting Dr. Eisenberg at www.daneisenberg.com

Visitor Comments: 3

(3)
Jay Lavine, M.D.,
December 23, 2014 9:49 PM

Jewish Medicine

Ethical lapses have indeed compromised the secular practice of medicine. Judaism, with its infinite respect for life, is the answer. Accordingly, I have created the Jewish Medicine website, whose focus is on the clinical practice of medicine.

(2)
Anonymous,
May 27, 2010 9:31 AM

Wonderful Article

As a student in the health profession I am often overwhen by the multitudes of lies taught in tertiary education. There is no doubt that moral decay has reached its limit when people can eliminate the innocent foes or weak individuals in society. These people blindly argue that it is ok are quick to condemn those who combine faitha and science together. I sincerely thank you for the article. HasShem bless you

(1)
Sarah,
August 7, 2004 12:00 AM

educational

I believe I can safely say that your articles are greatly appreciated by lay people like me (as well as doctors, of course!) who are interested in medical topics, especially Jewish medical ethics. Thank you so much!

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I just got married and have an important question: Can we eat rice on Passover? My wife grew up eating it, and I did not. Is this just a matter of family tradition?

The Aish Rabbi Replies:

The Torah instructs a Jew not to eat (or even possess) chametz all seven days of Passover (Exodus 13:3). "Chametz" is defined as any of the five grains (wheat, spelt, barley, oats, and rye) that came into contact with water for more than 18 minutes. Chametz is a serious Torah prohibition, and for that reason we take extra protective measures on Passover to prevent any mistakes.

Hence the category of food called "kitniyot" (sometimes referred to generically as "legumes"). This includes rice, corn, soy beans, string beans, peas, lentils, peanuts, mustard, sesame seeds and poppy seeds. Even though kitniyot cannot technically become chametz, Ashkenazi Jews do not eat them on Passover. Why?

Products of kitniyot often appear like chametz products. For example, it can be hard to distinguish between rice flour (kitniyot) and wheat flour (chametz). Also, chametz grains may become inadvertently mixed together with kitniyot. Therefore, to prevent confusion, all kitniyot were prohibited.

In Jewish law, there is one important distinction between chametz and kitniyot. During Passover, it is forbidden to even have chametz in one's possession (hence the custom of "selling chametz"). Whereas it is permitted to own kitniyot during Passover and even to use it - not for eating - but for things like baby powder which contains cornstarch. Similarly, someone who is sick is allowed to take medicine containing kitniyot.

What about derivatives of kitniyot - e.g. corn oil, peanut oil, etc? This is a difference of opinion. Many will use kitniyot-based oils on Passover, while others are strict and only use olive or walnut oil.

Finally, there is one product called "quinoa" (pronounced "ken-wah" or "kin-o-ah") that is permitted on Passover even for Ashkenazim. Although it resembles a grain, it is technically a grass, and was never included in the prohibition against kitniyot. It is prepared like rice and has a very high protein content. (It's excellent in "cholent" stew!) In the United States and elsewhere, mainstream kosher supervision agencies certify it "Kosher for Passover" -- look for the label.

Interestingly, the Sefardi Jewish community does not have a prohibition against kitniyot. This creates the strange situation, for example, where one family could be eating rice on Passover - when their neighbors will not. So am I going to guess here that you are Ashkenazi and your wife is Sefardi. Am I right?

Yahrtzeit of Rabbi Moses ben Nachman (1194-1270), known as Nachmanides, and by the acronym of his name, Ramban. Born in Spain, he was a physician by trade, but was best-known for authoring brilliant commentaries on the Bible, Talmud, and philosophy. In 1263, King James of Spain authorized a disputation (religious debate) between Nachmanides and a Jewish convert to Christianity, Pablo Christiani. Nachmanides reluctantly agreed to take part, only after being assured by the king that he would have full freedom of expression. Nachmanides won the debate, which earned the king's respect and a prize of 300 gold coins. But this incensed the Church: Nachmanides was charged with blasphemy and he was forced to flee Spain. So at age 72, Nachmanides moved to Jerusalem. He was struck by the desolation in the Holy City -- there were so few Jews that he could not even find a minyan to pray. Nachmanides immediately set about rebuilding the Jewish community. The Ramban Synagogue stands today in Jerusalem's Old City, a living testimony to his efforts.

It's easy to be intimidated by mean people. See through their mask. Underneath is an insecure and unhappy person. They are alienated from others because they are alienated from themselves.

Have compassion for them. Not pity, not condemning, not fear, but compassion. Feel for their suffering. Identify with their core humanity. You might be able to influence them for the good. You might not. Either way your compassion frees you from their destructiveness. And if you would like to help them change, compassion gives you a chance to succeed.

It is the nature of a person to be influenced by his fellows and comrades (Rambam, Hil. De'os 6:1).

We can never escape the influence of our environment. Our life-style impacts upon us and, as if by osmosis, penetrates our skin and becomes part of us.

Our environment today is thoroughly computerized. Computer intelligence is no longer a science-fiction fantasy, but an everyday occurrence. Some computers can even carry out complete interviews. The computer asks questions, receives answers, interprets these answers, and uses its newly acquired information to ask new questions.

Still, while computers may be able to think, they cannot feel. The uniqueness of human beings is therefore no longer in their intellect, but in their emotions.

We must be extremely careful not to allow ourselves to become human computers that are devoid of feelings. Our culture is in danger of losing this essential aspect of humanity, remaining only with intellect. Because we communicate so much with unfeeling computers, we are in danger of becoming disconnected from our own feelings and oblivious to the feelings of others.

As we check in at our jobs, and the computer on our desk greets us with, "Good morning, Mr. Smith. Today is Wednesday, and here is the agenda for today," let us remember that this machine may indeed be brilliant, but it cannot laugh or cry. It cannot be happy if we succeed, or sad if we fail.

Today I shall...

try to remain a human being in every way - by keeping in touch with my own feelings and being sensitive to the feelings of others.

With stories and insights,
Rabbi Twerski's new book Twerski on Machzor makes Rosh Hashanah prayers more meaningful. Click here to order...